Kurt W.G. Matthies is former computer engineer and freelance writer who has lived with the chronic intractable pain of severe spine disease for over 20 years. As a former Contributing Editor to MacUser and columnist for other trade journals, Kurt now writes about chronic pain for the National Pain Report. You can follow Kurt @kwgmatthies on Twitter.
As a writer and advocate with an intensely personal interest in the treatment of chronic pain, I try to stay current with available medical research related to our understanding of chronic pain and its treatment. In this time of great suffering in the chronic pain community, I take a special interest in medical research involving pain medication.
Let me back off for a moment. My training is in engineering. I’m not a doctor. Understandably, many wonder how I can read these esoteric scientific documents, or where I get my medical knowledge. So, allow me a moment to share some of my personal history.
When I was a teen many years ago, I took a terrible fall trying to learn “technical” mountain climbing. I was hospitalized for over two months, underwent the same surgery four times, and almost lost my life in that hospital due to an undiagnosed medical condition. The good news is that after a successful hematology grand round episode and some treatment with fresh-frozen plasma, I’m here to write the anecdote today.
It was in that hospital that I began to read medical textbooks. The practice became a habit that I developed in self-defense. I have a rare blood condition and I’ve had to educate most physicians about it throughout my life. For instance, because of my blood disease, I can’t take NSAIDs or I’ll develop an internal bleed. My chronic pain results from a severe case of spinal osteoarthritis (spondylosis), and what’s the first treatment most doctors think about when you’ve got arthritis – NSAIDs.
Through the years I’ve read my way through A&P, histology, hematology, neurology, and other fields, but for many years now I have focused entirely on subjects related to pain medicine. Reading medical lingo has become almost second nature.
Granted, reading medical literature is a strange hobby, but it’s mine.
Recently, I discovered the report of a medical study relevant to the special needs of people like me. This report was presented at the American Society of Anesthesiologists 2014 annual meeting and it examined the electronic medical records of VA patients who had inpatient surgery in 2011, excluding those whose diagnosis included cancer.
It seems doctors like to separate people in pain into two categories – those who have the pain of terminal cancer, and those of us who hurt real badly but aren’t yet terminal.
Please bear with me as I report a few technical details of this research.
The size of the sample group of this study, (usually called ‘n’ and an important factor in deciding the relevancy of any statistical study), included over sixty-four thousand subjects; primarily men between the ages of 55 and 65 years, white (80%), and that had significant comorbidities – a description that fits me to a T.
These 64,000+ subjects were stratified by the extent of their opioid regimen (if any) prior to surgery, as:
|Treatment Prior to Surgery||Length of Treatment (d)||Patient Population (%)|
|tramadol only||More than 90 days||8%|
|short-acting opioid||Less than 90 days||24%|
|Short-acting opioid (COT)||More than 90 days||17%|
|Long acting opioid (COT)||More than 90 days||5%|
After surgery, these patients were treated with opioids to control pain. In this study, researchers were interested primarily in measuring the number of days opioid analgesia was required after surgery. These findings are reported as follows:
|Treatment Prior to Surgery||Opioid Analgesia Required Post Surgery (in days)|
|short-acting opioid (< 90 d)||53|
|Short-acting opioid (COT)||365||or more|
|Long acting opioid (COT)||365||or more|
Study lead author, Seshadri C. Mudumbai, MD, a physician at the VA Palo Alto Health Care System commented on the results: “We found that opioid-naive patients would come off opioids quickly, but patients already on short-acting chronic opioids and long-acting opioids were basically on opioid regimens for the full year postoperatively or longer.”
He continued: “When we accounted for all factors, preoperative opioid burden was the strongest predictor for postoperative opioid use,” said Dr. Mudumbai. “Patients with short-acting chronic use and long-acting opioids were about nine times more at risk [italics mine] for prolonged opioid use versus patients who were opioid-naive before surgery.”
Wow. At risk?
These docs looked at a large population of patients who had surgery, some of whom needed chronic opioid therapy (COT) prior to surgery. They studied the length of time these people needed opioids after surgery and used it as a predictor of opioid needs in the COT group.
Sometimes people have surgery to treat a painful condition. I could expect a certain percentage in that sample group to stop using opioids after surgery.
But this study says nothing of the kind of surgery these patients underwent. Perhaps some of these were surgeries to reduce pain, but I would imagine that a great percentage of the 64,000 underwent a wide variety of surgeries, the kind of which is performed in VA hospitals all over the country.
So why in the world would you consider data regarding length of post-op opioid treatment in the two groups of patients that required COT prior to the study? People who require COT have chronic pain.
Dr. Mudumbai remarked that people with a history of prior chronic opioid use are “at risk” for prolonged opioid us post-surgery.
I ask – where’s the risk? They needed COT before their pain was exacerbated by surgery.
He continues with the statement that the COT group was “nine-times more at risk for prolonged opioid use.”
Nine-times more likely, Dr. Mudumbai? I’d say that these two groups formerly on COT were 100% more likely to require opioids during the entire year-long study period.
Their need for opioids had little to do with surgery or prior opioid use.
THEY NEEDED OPIATES BEFORE AND AFTER THEY UNDERWENT SURGERY BECAUSE THEY LIVED WITH CHRONIC PAIN!!!
Yes, the risk for needing opioids in the population that lives with chronic pain is high. For us, this is not a risk, but an essential medical treatment that allows us to live a productive life.
The word “risk” carries certain negative connotations.
Are hypertensives at risk for needing vasopressors? Are Type 2 diabetics, or people with COPD, coronary artery disease, or asthmatics at risk for requiring medication?
That’s one way of thinking about it.
But isn’t the medical treatment of disease an inevitable conclusion? Mr. Walgreens sure would have had to find another job if it weren’t. Where’s the risk?
How many of us are at risk of receiving a prescription for medication when we visit our doctor?
Was this yet another opioid-bashing report, exposing the researcher’s opioid bias?
There’s a name for an opioid bias. It’s called Opiophobia.
Risk or Opiophobia? What do you think?
Information from Clinical Pain Medicine, March 2015, Volume 13 was used in the preparation of this article.